Appropriate nursing interventions

  To use critical thinking and data collection to recognize and report complications that may impact the morbidity and mortality of clients who have sustained a traumatic insult to the urinary tract while functioning within the LPN scope of practice Competency Select appropriate nursing interventions for clients with disorders of the urinary system. Instructions Read the scenario below, and answer the questions. When you see a that means a clue. The Story It is Friday the 13th and a full moon. You are an LPN that normally works on a medical-surgical unit, but your unit is overstaffed, and the emergency department is short staffed. The nursing supervisor asks for a volunteer to go down to be an extra pair of hands. You volunteer as tribute. When you get to the ER, you are asked to do vitals on a client in the trauma room. The client is a 24-year-old male who was stabbed multiple times to the abdomen. The wounds appear superficial, and the client has been stable thus far. He will be going to CAT scan as soon as they can fit him in. You approach the client, who appears slightly pale with cool, clammy but is alert and talkative. The vital signs are: 97.3 (PO) P= 115 BP= 95/54 Resp rate= 24 Pain= 6/10. You notice the client voided 100 mL tea-colored urine in his urinal. One hour later, the client becomes unconscious. His pulse is now 144, and blood pressure is 70/50. The client is taken to the OR and has a nephrectomy for a very damaged and bleeding right kidney. Answer the following questions: • What were the clues in the data collection that should have alerted you and the staff that there might be a problem? (5-10 sentences) • Why is the urine “tea-colored?” (one sentence) • What are some other interventions that could have been done? (2-5 sentences) • Was the LPN in this scenario working within the scope of practice for an LPN? Why or why not? (5-10 sentences) • How did the environment of care (busy ER) contribute to the client’s deterioration? (5-10 sentences)

Sample Solution

   

Clues in Data Collection:

  1. Tea-colored urine: This indicates possible internal bleeding, a significant concern despite superficial external wounds.
  2. Pale skin and clammy skin: These suggest hypoperfusion, potentially due to internal blood loss.
  3. Elevated pain score: Although the client seemed talkative, a 6/10 pain score could indicate worsening internal injuries.
  4. Tachycardia (increased heart rate) and hypotension (low blood pressure): These vital sign changes, especially one hour later, point to hemodynamic instability, a serious warning sign.

Full Answer Section

       

Tea-colored Urine:

Blood in the urine, caused by internal bleeding, can cause the urine to appear tea-colored, a sign of potential kidney injury.

Alternative Interventions:

  1. Immediate notification of the physician: The observed clues warranted immediate escalation and reassessment by a doctor considering the potential internal injuries.
  2. Reexamination of the injury site: Checking for subtle changes in wounds or hidden internal bleeding points could have been crucial.
  3. Serial vital sign monitoring: More frequent vitals checks, especially after noticing the tea-colored urine, could have helped track the client's deterioration.
  4. Fluid resuscitation: Early intervention with IV fluids might have stabilized the client's declining blood pressure.

LPN Scope of Practice:

LPNs typically can:

  • Perform basic assessments, including vital signs.
  • Monitor patients for changes in condition.
  • Report observations and concerns to RNs or physicians.

However, LPNs generally cannot:

  • Make independent diagnoses.
  • Order or administer certain medications.
  • Perform invasive procedures.

Although the LPN in this scenario performed initial tasks within their scope, they should have escalated concerns about the tea-colored urine and deteriorating vital signs to an RN or physician who could initiate further diagnostics and interventions.

Environment of Care:

The busy ER environment likely contributed to the delayed escalation:

  • Distraction and time pressure: The chaotic emergency setting might have led to overlooking subtle clues or delaying notification.
  • Inadequate communication: Clear communication of observations and concerns between the LPN and other healthcare professionals might have been hampered by the busy environment.
  • Limited resources: Shortage of staff in the ER might have hindered timely reassessments and interventions.

In conclusion, recognizing and reporting potential complications like internal bleeding requires critical thinking and awareness of subtle clues beyond initial superficial appearances. Effective communication and escalation within the healthcare team are crucial in such situations, and even seemingly minor details like tea-colored urine can be crucial indicators of hidden dangers. While the LPN in this scenario performed certain tasks within their scope, timely escalation of concerns to higher-level staff could have potentially prevented the client's deterioration and resulted in a different outcome.

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